Provider Demographics
NPI:1255877429
Name:SHIELDS, TATYANA O (LCSW)
Entity type:Individual
Prefix:
First Name:TATYANA
Middle Name:O
Last Name:SHIELDS
Suffix:
Gender:
Credentials:LCSW
Other - Prefix:
Other - First Name:TATYANA
Other - Middle Name:O
Other - Last Name:GRAY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LCSW
Mailing Address - Street 1:3495 US HIGHWAY 1 STE 34 #1140
Mailing Address - Street 2:
Mailing Address - City:PRINCETON
Mailing Address - State:NJ
Mailing Address - Zip Code:08540-2603
Mailing Address - Country:US
Mailing Address - Phone:732-305-0335
Mailing Address - Fax:
Practice Address - Street 1:3495 US HIGHWAY 1 STE 34 #1140
Practice Address - Street 2:
Practice Address - City:PRINCETON
Practice Address - State:NJ
Practice Address - Zip Code:08540-2603
Practice Address - Country:US
Practice Address - Phone:732-305-0335
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-01-12
Last Update Date:2025-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ44SC059958001041C0700X
NY099773104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker